Potential implications of ABO blood group for vascular rejection in pig to human kidney xenotransplantation

Galactose α-1,3-galactose phenotypes: Lessons from various patient populations

OBJECTIVE

To review published studies on galactose α-1,3-galactose (α-gal), a carbohydrate epitope found on proteins and lipids in nonprimate mammals and present in foods (particularly organ or fat-rich red meat) and medications, where it causes delayed-onset and immediate-onset anaphylaxis.

DATA SOURCES

A literature search for the terms galactose α-1,3-galactose and α-gal using PubMed and Embase was performed.

STUDY SELECTIONS

Studies on α-gal were included in this review.

RESULTS

Several species of ticks contain α-gal epitopes and possibly salivary adjuvants that promote high titer sensitization and clinical reactivity. Risk factors for α-gal syndrome include exposure to ticks of particular species. Age and sex differences seen in various cohorts possibly reflect the prevalence of these exposures that vary according to setting.

CONCLUSION

The reason and mechanisms for delayed onset of food-related anaphylaxis and the preponderance of abdominal reactions are not clear but may involve the kinetics of allergen digestion and processing or immunologic presentation via a different mechanism from usual immediate-type food allergy.

Investigation into the α-Gal Syndrome: Characteristics of 261 Children and Adults Reporting Red Meat Allergy

BACKGROUND

Red meat allergy has historically been understood as a rare disease of atopic children, but the discovery of the "α-Gal syndrome," which relates to IgE to the oligosaccharide galactose-α-1,3-galactose (α-Gal), has challenged that notion.

OBJECTIVE

To describe the clinical and immunologic characteristics of a large group of subjects with self-reported allergy to mammalian meat.

METHODS

This was an observational study of 261 children and adults (range, 5-82 years) who presented for evaluation for allergic reactions to mammalian meat. Results were based on serum assays and a detailed questionnaire.

RESULTS

α-Gal specific IgE ≥ 0.35 IU/mL was detected in 245 subjects and symptom onset occurred ≥2 hours after eating mammalian meat in 211 (81%). Component testing supported a diagnosis of α-Gal syndrome in 95%, pork-cat syndrome in 1.9%, and primary beef allergy in 1.1%. Urticaria was reported by 93%, anaphylaxis by 60%, and gastrointestinal symptoms by 64%. Levels of IgE and IgG specific to α-Gal were similar in subjects who reported early- or delayed-onset symptoms, and in those with and without anaphylaxis. Levels of α-Gal specific IgE and severity of reactions were similar among those with and without traditional atopy, and among children (n = 35) and adults (n = 226). Blood group B trended toward being under-represented among α-Gal-sensitized subjects; however, α-Gal specific IgE titers were high in symptomatic cases with B-antigen.

CONCLUSIONS

The α-Gal syndrome is a regionally common form of food allergy that has a characteristic but not universal delay in symptom onset, includes gastrointestinal symptoms, can develop at any time in life, and is equally common in otherwise nonatopic individuals.

Distribution of the alphaGal- and the non-alphaGal T-antigens in the pig kidney: potential targets for rejection in pig-to-man xenotransplantation

Carbohydrate antigens, present on pig vascular endothelial cells, seem to be the prime agents responsible for graft rejection, and although genetically modified animals that express less amounts of carbohydrate antigen are available, it is still useful to decide the localization of the reactive xenoantigens in organs contemplated for xenotransplantation. Here we compare the distribution in pig kidney of antigens important in xenograft destruction, namely the Galalpha1-3Gal (alphaGal) glycans, with the localization of the T-antigen (Galbeta1-3GalNAc). The alpha-galactose-specific lectin Griffonia simplicifolia isolectin 1B4 was used to detect the Galalpha1-3Gal glycans, whereas Arachis hypogaea (PNA) lectin and a monoclonal antibody (3C9) detected T-antigen. In addition, two vascular markers (anti-caveolin-1 and anti-von Willebrand factor) served to identify vascular structures of the kidney. Both conventional fluorescence and confocal microscopy were used to distinguish lectin and immunohistochemical staining. On the basis of fluorescence signals, the results indicate that the carbohydrate antigens are heterogeneously distributed in the pig kidney. alphaGal epitopes were sparse in the capillary loops forming the glomeruli and in the capillaries surrounding the convoluted tubules, but showed stronger staining in capillaries surrounding the limbs of Henle. In addition, the brush border and basement membranes of the convoluted tubules strongly reacted with the GS1-B4-lectin. Finally, the Galalpha1-3Gal glycans were also present on epithelial cells of the large collecting tubules. Regarding the T-antigen, PNA and 3C9 reacted with different glomerular cells, whereas both reacted strongly with the endothelial cells lining the large kidney vessels. Human serum incubation of pig kidney sections, in which the alphaGal epitopes were blocked by unconjugated GS1-B4, showed staining of the same vascular structures as were obtained after incubation with the T-antigen-detecting agents. The study thus proves a complex spatial distribution of carbohydrate antigens relevant for xenotransplantation of pig kidney.

Reactivity of human natural antibodies to endothelial cells from Galalpha(1,3)Gal-deficient pigs

BACKGROUND

Xenoreactive human natural antibodies (NAb) are predominantly directed against galactose-alpha(1,3)galactose (Gal). Binding of immunoglobulin (Ig) G and IgM NAb activates porcine endothelial cells (pEC) and triggers complement lysis responsible for hyperacute xenograft rejection. In vitro, IgG NAb induce human natural killer (NK) cell-mediated lysis of pEC by antibody-dependent cell-mediated cytotoxicity (ADCC). The present study examined the levels of anti-porcine NAb in a large number of individuals and addressed the functional role of non-Gal anti-porcine NAb.

METHODS

Sera from 120 healthy human blood donors were analyzed for the presence of anti-porcine NAb by flow cytometry using porcine red blood cells (pRBC), lymphoblastoid cells (pLCL), and pEC derived from control or Gal-deficient pigs. Xenogeneic complement lysis was measured by flow cytometry using human serum and rabbit complement. ADCC was analyzed by chromium-release assays using human serum and freshly isolated NK cells.

RESULTS

Human IgM binding to pRBC was found in 93% and IgG binding in 86% of all samples. Non-Gal NAb comprised 13% of total IgM and 36% of total IgG binding to pEC. NAb/complement-induced lysis and ADCC of Gal-deficient compared to Gal-positive pEC were 21% and 29%, respectively. The majority of anti-Gal and non-Gal IgG NAb were of the IgG2 subclass.

CONCLUSIONS

The generation of Gal-deficient pigs has overcome hyperacute anti-Gal-mediated xenograft rejection in nonhuman primates. Non-Gal anti-porcine NAb represent a potentially relevant immunological hurdle in a subgroup of individuals by inducing endothelial damage in xenografts.

In pursuit of xenoreactive antibodies: Where has it gotten us?

Numerous studies have aimed to overcome the barrier to xenotransplantation posed by xenoreactive antibodies and the antigens they recognize. Whether this work will eventually lead to the widespread clinical application of xenotransplantation remains unknown. However, the benefits of this research are already substantial, with research leading to dramatic new developments in fields other than xenotransplantation. Our understanding of natural immunity, particularly the nature and function of natural antibodies, has taken quantum leaps forward, with far-reaching implications. Our improved understanding of the immune response to xenografts has proven invaluable in the characterization of the human immune reaction to commonly used biological therapeutics of xenogeneic origin. Our understanding of cell surface carbohydrates and our ability to modify these carbohydrates in living animals has advanced substantially, with implications for diseases such as cancer and autoimmunity. With this in mind, it is argued that continued work in xenotransplantation is of great value, not only because of the great potential benefits of xenotransplantation, but also because of the more certain benefits that arise from setting our sights on a difficult challenge.